In this two part article, I am reviewing the basis for the serious problem we have in providing adequate health care for Australians who live in rural, and particularly, remote areas. Good intentions are, as ever, intertwined with political machinations which make policies for solutions harder to implement. Currently, yet another government review is soon to be released. Here is the background needed for judging the results.
In part one I mentioned four major reviews of the strategies required to have more Australian trained doctors practice in rural communities. The major recommendations in all four were similar. Governments of both major parties have largely ignored them. Compelling evidence tells us that to solve this problem we need to train young men and women who love rural life, are living such a life at the time of enrollment in medical school. We need students excited about the prospect of a career as a doctor in a rural community. We need to train such people in the country using a rural specific curriculum that equips the student to deal with the epidemiological realities of rural life and provides them with procedural skills not needed for city practice. The shortage of specialists make this approach important. To minimize the attrition rate associated with time spent in the city, the course should be an undergraduate one of six years. It is recognized by the AMA and Medical colleges that, in addition to the medical school initiatives describe above, all of a doctor’s post graduate vocational training would need to be available in rural settings. Indeed, the required master plan must address school, university and post graduate education in rural Australia.
Looking at the challenges associated with such a plan it becomes obvious that to enroll the number of medical students required, we would need to have an “affirmative” action program that would feature an interview of candidates to assess their rurality and acceptance of a slightly lower university entrance score than that currently required by major universities. “Rural students” in our metropolitan universities must meet the same university entrance score requirements asked of city students. Such a suggestion has led to some saying you would in so doing be lowering the standard of medical excellence! There is absolutely no evidence nor logic in thinking that a few points of difference would affect the outcomes of a six-year medical course. It is an important strategy for there is educational disadvantage in much of rural Australia with poorer school facilities seeing far fewer students in rural schools meeting the entrance scores asked for by major universities. Certainly, rural based universities need to work with state governments and their schools to address inadequacies and alert students to possibilities that previously did not exist.
Another imperative has become obvious. A rural based medical school would need to focus on making sure that student attachments to small town practices result in a positive experience. Too often today students come back from two weeks in a remote or very small town where they may be only one or two doctors, saying “those guys are saints but the one thing I am sure about is that small town practice is not for me.” A rural university working with the local community and its clinicians can do much to improve the clinical environment, with practitioners feeling less isolated as they become part of, and important to, the university program. Much of the above is incorporated into the program run by rural based James Cook University with 60% of its graduates practicing in a rural Queensland setting.
Trying to build on this success and add additional needed initiatives is not easy. The last thing we need today is more medical students. There is a crisis already in finding post graduate internship programs for current graduates and we will soon have more doctors than we need. Our problem is maldistribution of those numbers and I have argued that that problem can only be solved overtime by the rural training programs outlined. Unfortunately, the government has been reluctant to take some existing university places and redistribute them to rural based programs. Places come with money and universities are reluctant to lose them. Instead a number of metropolitan universities have decided to set up small satellite medical schools in a rural setting. Often the plans involve satellites with 20-30 students chosen by the usual criteria, (20 in Pt Macquarie, 20 in Gippsland, 20-30 in Wagga Wagga).
Even if some students could be attracted to a rural setting for education with a small number of colleagues one feels that such students would miss out on the advantages of learning and maturing on a university campus where many non-medical interests could develop. The Minister for rural health, Dr. David Gillespie ordered a review of the case for redistribution of medical student places to rural based universities and the results should be public by June. However, on the weekend the government announced that a new medical school would be established on the sunshine coast with places redistributed from the University of Queensland or from the medical school Griffith university runs on the Gold Coast! How could this decision have been reached before the review mentioned is completed?
The only proposal that addresses all the evidence based requirements for retention of graduates in rural communities (that I have detailed above) come from a partnership between Charles Sturt and La Trobe universities who are dedicated to establishing a Murray Darling Medical school with campuses in Orange and Bendigo. I have been acting as a consultant to that plan for a number of years. However, the current environment surrounding ways to improve the health of rural Australians is so political, so strangled by vested interests and, at a policy level, so far removed from evidence based influence that one can have no confidence that the major changes described here will get the support needed. Rural Australians will have every reason to be angry if support is not forthcoming.
John Dwyer is Emeritus Professor of Medicine at UNSW